New Client Inquiry Form

We look forward to hearing from you. You will recieve a quicker and more efficient response when all applicable fields are filled out. All information provided is fully encrypted and HIPPA compliant. We will use this information to do a benefits check and determine available therapists based off the information provided and provider availibility.

IMPORTANT: Please provide an accurate phone number as this will be the way you will be contacted.

Name of person filling out this form

Name of potential client

Address

City

State

Zip

Phone

Date of birth (potential client)

How did you hear about us?

Preferred Provider (if known)

Name of Insurance Company

Member/Subscriber ID# (including alpha prefix if there is one)

Insurance Group #

Insurance contact phone # for providers (back of ins. card)

Customer service phone # (back of ins. card)

Insured Subscribers Name as shown on card (if different from self)

Subscribers date of birth

Subscriber relationship to client

Subscribers address

Subscribers phone number

Provider One ID (for Medicaid plans only)

What do you want to work on in therapy?

Is there a particular type of treatment you are looking for?

Cognitive Behavioral Therapy

EMDR

Parent Child Interactive Therapy

Acceptance and Commitment Therapy

Solution Focused

Other

I'm Unsure

Please list any current or previous mental health diagnosis:

Is there anything else I need to know to better pair you with the right clinician?

Comments

Your message will be encrypted and can only be read by Trauma Informed Therapies, PLLC & A Refuge:Trauma Informed Therapies, A Nonprofit Organization.